Transcript Palliative Care

Palliative Care
Eyad Al-Saeed, MD,FRCPC
Consultant Radiation Oncology
Prince Sultan Hematology Oncology
Center
Brain Metastases
Most common intracranial tumor
Most common primary (lung,breast,melanoma (
Hemorrhagic Metastases( renal cell CA,
choriocarcinoma,melanoma (
Clinical Presentation
Symptoms
%
Signs
%
Headache
49
Impaired cognition
58
Focal weakness
30
Hemiparesis
59
Mental disturbance
32
Hemisensory loss
21
Gait Ataxia
21
Papilledema
20
Seizures
18
Gait Ataxia
19
Speech diff
12
Aphasia
18
Sensory disturbance
6
Visual field cut
7
Visual disturbance
6
Limb Ataxia
6
Limb Ataxia
6
LOC
4
Diagnostic Studies
CT •
MRI •
? Primary •
a =5anterior cerebral artery m = middle cerebral artery fh = frontal horn - lateral ventricle
ph = posterior horn - lateral ventricle cc = corpus callosum
6
Cranial structures
7
1.Hard Palate
2.Nasopharynx
3.Sphenoid air sinus
4.Pituitary gland
5.Frontal sinus
6.Frontal lobe
7.Corpus callosum
8.Septum pellucidum
9.Parietal lobe
10.Fourth ventricle
11.Occipital lobe
12.Cerebellum
13.Sinus Confluence
14.Pons
15.Medulla Oblongata
16.Spinal Cord
8
Prognostic Factors
Class
Characteristics
Survival
1
KPS 70-100
Primary Controlled
Age < 65
Mets to brain only
7.1 mo
2
All Others
4.2 mo
3
KPS < 70
2.3 mo
Treatment
Steroids •
•
improved headache and neurological function •
No impact on survival •
Start dexamethason 4mg q 6h if patient has •
neurological symptoms
Taper as tolerated •
No role for steroids in asymptomatic patients •
CONT..
Characteristics
Options
Single lesion
(1 – 2)
Surgical resection +WBRT
WBRT+SRS
SRS alone (with SRS or WBRT for salvage prn)
WBRT alone
2-4 lesions
( 1-2)
WBRT alone
WBRT + SRS
SRS alone (with SRS or WBRT for salvage prn)
controversial
4 lesion
(1-2)
WBRT alone
WBRT + SRS controversal
SRS alone ( with SRS or MBRT for salvage prn )
controversal
class 3
WBRT alone
Spinal cord compression
Anatomy •
Extends from foramen magnum to L1 – L2 •
Below the termination of the cord it contains the •
lumber cistern, an enlargement of the
subarachonoid space that surrounds the cauda
equina.
SAS terminates inferiorly at S2 – S3. •
•
Clinical Presentation
Pain (90%-95%),usually precedes all other •
symptoms by several weeks to months
Weakness is rarely the first symptom (2%)but is •
fairly common at diagnosis (75%).
Sensory loss (50%) •
Autonomic dysfunction associated with •
unfavorable prognosis and late (50%) •
Once neurologic deficits develop, impairment •
progresses rapidly.
Diagnostic imaging
MRI (Gold standard if neurological symptoms(
CT •
Conventional Myelography •
XRay •
Treatment
Steroid to be started immediately and then taper •
as tolerated •
Surgery as a first line if •
1- diagnosis unknown or doubtful for malignancy •
2-instability of spine or bony compression of the •
cord
3- previous radiation of the site of compression •
4- progression during radiation •
5- contra indication of radiation or radiation •
resistant tumor.
CONT..
Radiation •
Post op •
Alone if multiple levels of compression or •
poor performance status patient.
Superior Vena Cava Syndrome
Superior Vena Cava Syndrome is a medical
emergency occasionally seen in patients with
malignant tumor that requires immediate action
Causes
1- bronchogenic carcenoma 80 %
2- Malignant lymphoma 10 - 18%
3- Benign 2-3%
Diagnosis
Biopsy •
CT •
1 = carina 2 = left main bronchus 3 = right main bronchus
4 = right upper lobe bronchus 5 = descending aorta 6 = superior vena cava
Treatment
1- Radiation •
2- Chemotherapy in case of Small Cell Lung •
Cancer Or Lymphoma
3- Steroids •
4- ? Diuretics •
Bone Metastases
Common cause of severe cancer pain •
Good pain control may improve OS •
Sites of mets : Spine (Lumber > Thoracic) > •
Pelvis > Ribs >femur >Skull
Primary ( breast, Prostate, Thyroid, Kidney. •
Lung)
Workup
Bone scan is the primary imaging modality •
Plain films looking for fracture •
MRI for Spinal cord •
Biopsy if unknown primary •
Treatment
1- Supportive including pain control •
2-Surgery incase of fracture or impending •
fracture
3- Radiation •